The state Department of Financial Services approved CVS Health's $69 billion acquisition of insurer Aetna on Monday morning, lifting the final barrier to the deal's closure.
Aetna said in a Securities and Exchange Commission filing the companies expect the deal to close on Wednesday.
The U.S. Department of Justice approved the purchase in October and the companies have already received all other necessary approvals from other states. Bloomberg News reported that 28 states, including New York, weighed in on the combination of the nation's largest drugstore chain and one of the nation's largest health insurers.
DFS said it received commitments that the costs of CVS' acquisition will not be passed on to Aetna customers in New York in the form of higher premiums. CVS also agreed to provide $40 million to the state to support health insurance education and enrollment, including payments to the state's Health Care Transformation Fund. That fund has been used previously by the Cuomo administration to support struggling hospitals.
"DFS listened to the concerns of the public and has obtained significant commitments from CVS and Aetna to address those concerns, ensuring that the companies hold to their promises of reduced costs and improved health care for New Yorkers," DFS Superintendent Maria Vullo said in a statement.
The department held a public hearing on Oct. 18 with local trade groups representing pharmacists and physicians who opposed the transaction. CVS Caremark is one of the three biggest pharmacy benefit managers, which negotiate drug prices on behalf of insurers, employers and union benefit funds. Opponents said the deal would limit competition.
CVS and Aetna have said their combination will lead to lower costs for consumers and greater access to care through a network of health clinics at CVS stores. The chain and its subsidiaries own 573 pharmacies in the state. Aetna received about $3.5 billion in premiums from New York customers last year, according to DFS.
To win approval from New York, CVS also agreed not to offer any preferential pricing to Aetna-affiliated insurers in the state and to continue to include non-chain pharmacies in its local networks for at least three years.
The health plan will maintain its current set of insurance products for three years, add an additional product in the small- or large-group market and document the "synergies" it said it would create by combining with CVS.
The Cuomo administration has previously supported legislation that would require that pharmacy benefit managers, including CVS Caremark, are licensed and regulated by the Department of Financial Services. A previous bill was not ultimately approved by the state Legislature but DFS said Monday that CVS Health has agreed to "take no action to oppose such future legislation."
Dr. Thomas Madejski, president of the Medical Society of the State of New York, said he supported the Cuomo administration’s push for legislation to more closely monitor pharmacy benefit managers. He said the "enormous power" of the combined company would marginalize physicians.
"Physicians fully expect that the merger will further reduce competition in New York’s health insurance market," he said in a statement. "This is one more reason why physicians deserve the right to collectively."
JONATHAN LAMANTIA CRAIN'S NEW YORK BUSINESS
PM Pediatrics, an urgent-care chain for kids, has opened its 35th location in Wayne, Pa., near Philadelphia, marking the seventh state for the fast-growing company. The Lake Success, Long Island–based chain treats children and adolescents exclusively and hires physicians who specialize in pediatric emergency care to handle cases including fevers, fractures and wounds.
Dr. Jeffrey Schor, the company's founder and co-CEO, said PM Pediatrics seeks to complement primary care practices by operating from noon to midnight Monday through Saturday and 10 a.m. to midnight Sundays and holidays. It also does not perform immunizations or physicals and encourages patients to follow up with a primary care doctor. We capture the peak hours when children would otherwise have to go to the emergency room," Schor said.
Schor said Pennsylvania fit well with the rest of the company's portfolio, which includes locations in southern New Jersey and Maryland. It has 18 New York locations, including eight on Long Island.
The area where the new clinic is located had a median household income of $122,000 in 2016—about double the national average. Schor noted that PM Pediatrics takes most major Medicaid plans and will do so in this new location.
He said he expects the company to reach 60 locations by the end of next year. Its expansion has been aided by $48 million from private investors, including Scopia Capital. —J.L.
NEW CITY, N.Y. – The number of measles cases in the United States so far this year has surpassed 2017 with the potential for about a quarter of the highly contagious respiratory infections to be occurring in one New York county north of New York City.
Nationwide as of Oct. 6, the most recent nationwide data available, 142 measles cases had been reported, according to the federal Centers for Disease Control and Prevention. The number of people sickened, mostly unvaccinated, exceeded the 2017 total of 120 in mid-August.
As of Friday, Rockland County had 46 confirmed cases and nine suspected cases, according to the county's health commissioner, Dr. Patricia Ruppert. A month ago, Rockland County Health Department officials were worried about an outbreak and offering emergency measles vaccination clinics because a traveler from Israel had visited an ultra-Orthodox Hasidic synagogue and a sukkah, a temporary structure built for the weeklong Jewish festival of Sukkot, near a Jewish boys school in New Square, New York.
"There's a component ... that are not in favor of vaccines," said Dr. Howard Zucker, New York state's health commissioner. "We need to dispel any worries that they have."
None of those infected in Rockland County were fully vaccinated, Ruppert said. The state has banned unvaccinated students from attending classes in three communities if their school has a vaccination rate of 70 percent or lower.
Two doses of the measles, mumps and rubella vaccine, generally given at age 12 to 15 months with a booster at 4 to 6 years old, are 97 percent effective in preventing measles. One dose is 93 percent effective, according to the CDC.
“I've seen these diseases, all of them, diptheria to measles. I've seen the measles encephalitis. ... I don't think any parent would want to experience that with a child.”
The measles virus is transmitted via the misty droplets that come when an infected person coughs, sneezes and even breathes. The virus can live up to two hours in the air and on surfaces in a room where an infected person has been.
Someone infected can transmit the disease from four days before to four days after a flat, itchy, red rash shows up. Measles symptoms may not appear for a week to three weeks after exposure.
While Rockland County's overall vaccination compliance rate is 94 percent, Orthodox Jewish schools in the area vary widely in vaccination rates from 40 to 100 percent.
The World Health Organization considers herd immunity to be achieved when a community has 95 percent of its members vaccinated. This helps protect those who cannot receive vaccinations because they are too young, have immune system problems or are too ill to get the shots.
Nationwide in the 2017-18 school year, 94.3 percent of kindergarteners in 49 of 50 states had received both doses of the MMR vaccine, the CDC said.
The outbreak in Rockland County, about 25 miles north of New York City, is one of 11 outbreaks in 25 states reported so far this year. States affected are Arkansas, California, Connecticut, Florida, Illinois, Indiana, Kansas, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nebraska, Nevada, New Jersey, New York, North Carolina, Oklahoma, Oregon, Pennsylvania, Tennessee, Texas, Virginia and Washington.
South Carolina is not on the CDC's most recent list; however, three cases have been confirmed in the past week in Spartanburg County, according to the South Carolina Department of Health and Environmental Control. Three or more linked cases constitute an outbreak.
Rockland County's measles outbreak and cases in New York City – and Bergen County and Lakewood, New Jersey – have been linked to Israel.
An 18-month-old unvaccinated girl died from complications of measles Thursday in Jerusalem, the country's first measles death in 15 years, according to The Jerusalem Post. Nearly 1,300 cases in the country of 8.5 million residents have been reported so far this year; in contrast, the United States has about 329 million people.
Needles used in a free measles vaccination clinic Nov. 2, 2018, in Monsey, N.J., are put into medical waste containers. (Photo: Rochel Leah Goldblatt, The (Westchester/Rockland county, N.Y.) Journal News)
Meanwhile, an outbreak in Europe has left more than three dozen dead.
General skepticism about vaccinations, including the MMR shots, continues among some, no matter where they live.
This questioning of vaccines plays out in different ways, though. Some swear off all vaccines, believing they carry more risks than the diseases they are designed to fight.
Other parents remained concerned about what they see as an overwhelming and aggressive vaccination schedule.
They may want to slow the amount of shots given or skip certain inoculations. In a vacuum, they may opt out of vaccinations because they don't think their ideas will be welcome.
Ruppert said she's been talking with families who are "in between," who focus on delaying a vaccination schedule. She has found them amenable to education and explanation if their concerns are respectfully addressed.
Part of today's problem has been the success of childhood immunizations in previous generations, said Zucker, who is a pediatrician with a subspecialty in critical care. People aren't familiar with many of the diseases that killed or maimed children as few as 25 years ago; the chicken pox vaccine was introduced in the United States in 1995.
"I've seen these diseases, all of them, diptheria to measles," he said. "I've seen the measles encephalitis, I've seen whooping cough. I don't think any parent would want to experience that with a child.
"I recognize the worries of this," Zucker said of parents' concerns. "But I recognize the need for vaccinations."
Because the vaccinations prevent diseases, they don't see what could happen, he said.
Complications of measles include pneumonia, brain damage, deafness and death. The disease can be dangerous, especially for babies, young children and pregnant women who haven't had the virus.
A clinic Friday in Monsey, New York, drew 99 people. One child was turned away because he showed symptoms of measles, Ruppert said.
"If they're looking sick, they don't come in the building," she said, explaining that every person is given a quick analysis at the door so anyone infected doesn't end up spreading the virus at the clinic. She was gratified that the parents of the sick child decided to have the siblings receive the vaccine anyway.
Contributing: Liv Osby, The Greenville (S.C.) News; USA TODAY. Follow Nancy Cutler on Twitter: @nancyrockland
Walmart and the parent company of Mucinex are partnering with Doctor On Demand, a virtual care provider headquartered in California that has spread nationwide and is steadily expanding.
On Wednesday, RB, the English-based health and hygiene company, announced that consumers who purchase their products Mucinex, Airborne or Digestive Advantage at Walmart stores or through walmart.com would receive a limited-time offer for a medical video visit with a Doctor on Demand physician at no cost.
Doctor on Demand already has a number of direct contracts with large employers including Walmart, Wells Fargo, Comcast, American and United Airlines. Employees at these companies are able to use Doctor on Demand services.
WHY THIS MATTERS
Virtual care is a big part of the future of healthcare. It is not replacing face-to-face physician visits, but represents a less expensive, more convenient consumer care experience, exactly the direction the healthcare industry has been told to head.
In-office visits are more expensive and time-consuming, Doctor on Demand said. Plus, 30 percent of adults don't have a primary care physician.
The Centers for Medicare and Medicaid Services and private health plans are increasingly reimbursing providers for telehealth.
Doctor on Demand works with national health plans such as UnitedHealthcare and Humana and others, which pay less for the virtual services than in-patient care.
Medicare will begin allowing monitoring from homes starting in 2020 and other changes are coming that will further open up the business.
Doctor on Demand got onboard the virtual visit trend before it crested and has been riding it to success.
The company has grown with smartphone adoption, according to Dr. Ian Tong, chief medical officer at the San Francisco headquarters.
When Doctor on Demand launched in 2012, it was a direct to consumer medical company. It then began adding large companies. It also expanded into rural areas such as in upstate New York, where Doctor on Demand is an in-network provider.
Patients accessed a video-based virtual visit through a mobile device.
Consumers wearing a Fitbit or who have a smartphone can download an app that gives the heart rate, oxygen saturation or an EKG reading.
Doctors use a mobile device camera to see down the back of throats, a method that works as well, or even better, than a tongue depressor, Tong said.
The company developed its own EMR and embedded the video component in its platform, so patients and physicians are seeing the same health information.
The majority of patients are between the ages of 25 and 50. About 10 percent of its patient population is between the ages of 50-55, and that drops to 8 percent for those aged 55-65.
Physicians are attracted to the business model because they can work from home.
The company isn't paying the overhead for real estate and to staff buildings. Doctor on Demand has three offices to handle administrative work.
The core message is that virtual care works as well as an office visit. But it's not meant to displace primary care physicians.
An audit run by Humana showed virtual visits have similar results to in-person visits as far as how many patients revisited their provider.
Humana assessed the severity score and diagnosis comparison and followed with claims data 14 days later.
The rate for those patients going to the emergency room who had used Doctor on Demand was 1.3 percent, compared to 1.1 percent for those who originally went into an office.
The antibiotic fill rates were 36.1 percent for telemedicine and 40 percent for in-office visits.
Doctor on Demand did have a higher 14-day revisit rate to urgent care than those who had seen a physician in-person. The revisit rate for Doctor on Demand was 0.9 percent, compared to 0.1 percent for in-office.
Email the writer: email@example.com
By Blake Dodge
October 18, 2018, 6:11 PM EDT Updated on October 19, 2018, 6:48 AM EDT
New York state officials are considering blocking parts of the $68 billion merger of drugstore store chain CVS Health Corp. and Aetna Inc., jeopardizing billions of dollars in insurance premiums for Aetna.
CVS and Aetna won approval from the U.S. Justice Department on Oct. 10, contingent on Aetna divesting its Medicare Part D business, which covers prescription drugs for seniors. But the deal still needs to pass through state regulatory bodies.
At a public hearing in Manhattan on Thursday, Maria Vullo, superintendent of the state Department of Financial Services, said her agency might block CVS’s merger with Aetna’s New York unit. She called U.S. approval of the overall deal “myopic” and repeatedly asked CVS and Aetna representatives for written evidence that they would deliver on promises to lower prices.
Several groups, including the Pharmacists Society of the State of New York and the Medical Society of the State of New York, urged the state to block the deal. They said the merger would limit competition and drive up the cost of prescription drugs. Assemblyman Richard Gottfried, chairman of the Health Committee, said the deal introduces “dangerous trends” in consumer access.
While CVS has said in the past that the merger would result in lower costs for consumers, Elizabeth Ferguson, deputy general counsel for CVS, told Vullo there wasn’t a specific plan to lower prices.
CVS and Aetna announced the deal in December 2017 but continue to face regulatory hurdles. Connecticut approved the deal Oct. 17, and the New York will reach a decision after Oct. 25.
Shares of CVS and Aetna were little changed in New York Thursday.
Berkshire Hathaway subsidiary National Indemnity Co. closed its $2.5 billion purchase
New York physicians who are members of the malpractice insurer MLMIC have a new backer as they fight lawsuits from patients: billionaire Warren Buffett.
Berkshire Hathaway subsidiary National Indemnity Co. closed its $2.5 billion purchase of MLMIC on Oct. 1 after receiving approval from the state Department of Financial Services and MLMIC policyholders.
Buffett appeared Wednesday on a live-stream video from Omaha, Neb., with Dr. James Reed, MLMIC chairman, to discuss the transaction and the health care industry.
The acquisition gives physicians insured by MLMIC the financial backing of a company worth more than $520 billion.
Buffet said he views medical malpractice coverage as particularly important because, unlike home or auto coverage, the insurer is defending a physician's reputation.
"We're going to defend the physicians," he said, "even if sometimes it makes sense to settle and pay the lawyer's fees and move on."
Reed, who is also CEO of the nonprofit St. Peter's Health Partners system in Albany, said changes in the health care industry, including the consolidation of medical practices and hospitals, have stoked fear among physicians.
"There's a lot of uncertainty in New York state," he said. "What we want to do is take this uncertainty off the table."
One issue doctors are watching closely, he said, is the health care partnership between Amazon, Berkshire Hathaway and JPMorgan Chase.
Buffett continued to keep details scant about the venture, which is being led by Dr. Atul Gawande, a surgeon and author. The size of all three employers will be helpful in achieving their goals of promoting better care at a lower cost, Buffett said.
He said the partnership is "really at the embryonic stage"—without timetables. "It's a little like when Columbus sailed," he said. "We don't know exactly where we're going, and we hope we won't fall off a shelf."
By Lena H. Sun
A small but increasing number of children in the United States are not getting some or all of their recommended vaccinations. The percentage of children under 2 years old who haven’t received any vaccinations has quadrupled in the last 17 years, according to federal health data released Thursday.
Overall, immunization rates remain high and haven’t changed much at the national level. But a pair of reports from the Centers for Disease Control and Prevention about immunizations for preschoolers and kindergartners highlights a growing concern among health officials and clinicians about children who aren’t getting the necessary protection against vaccine-preventable diseases, such as measles, whooping cough and other pediatric infectious diseases.
The vast majority of parents across the country vaccinate their children and follow recommended schedules for this basic preventive practice. But the recent upswing in vaccine skepticism and outright refusal to vaccinate has spawned communities of under-vaccinated children who are more susceptible to disease and pose health risks to the broader public.
Of children born in 2015, 1.3 percent had not received any of the recommended vaccinations, according to a CDC analysis of a national 2017 immunization survey. That compared with 0.9 percent in 2011 and with 0.3 percent of 19- to 35-month-olds who had not received any immunizations when surveyed in 2001. Assuming the same proportion of children born in 2016 didn’t get any vaccinations, about 100,000 children who are now younger than 2 aren’t vaccinated against 14 potentially serious illnesses, said Amanda Cohn, a pediatrician and the CDC’s senior adviser for vaccines. Even though that figure is a tiny fraction of the estimated 8 million children born in the past two years who are getting vaccinated, the trend has officials worried.
“This is something we’re definitely concerned about,” Cohn said. “We know there are parents who choose not to vaccinate their kids . . . there may be parents who want to and aren’t able to” get their children immunized.
Some diseases, such as measles, have made a return in the United States because parents in some areas have failed to vaccinate their children. Last year, Minnesota suffered the state’s worst measles outbreak in decades. It was sparked by anti-vaccine activists who targeted an immigrant community, spreading misinformation about the measles vaccine. Most of the 75 confirmed cases were young, unvaccinated Somali American children.
The data underlying the latest reports do not explain the reason for the increase in unvaccinated children. In some cases, parents hesitate or refuse to immunize, officials and experts said. Insurance coverage and an urban-rural disparity are likely other reasons for the troubling rise.
Among children aged 19 months to 35 months in rural areas, about 2 percent received no vaccinations in 2017. That is double the number of unvaccinated children living in urban areas.
The new data shows health insurance plays a significant role, as well. About 7 percent of uninsured children in this age group were not vaccinated in 2017, compared with 0.8 percent of privately insured children and 1 percent of those covered by Medicaid.
Those differences are concerning because uninsured and Medicaid-insured children are eligible for free immunizations under the federally funded Vaccines for Children program.
“Parents may not be aware of this, so this may be an education issue,” Cohn said.
Other issues, such as child care, transportation and a shortage of pediatricians in rural areas, also are likely to affect vaccination coverage.
A second report on vaccination coverage for children entering kindergarten in 2017 also showed a gradual increase in the percentage who were exempted from immunization requirements. (The exemptions do not distinguish between one vaccine vs. all vaccines.)
All but a handful of states allow parents to opt their children out of school immunization requirements for nonmedical reasons, providing exemptions for religious or philosophical beliefs.
The overall percentage of children with an exemption was low — 2.2 percent. But the report noted that “this was the third consecutive school year that a slight increase was observed.” The report does not provide a breakdown, but the majority of exemptions are nonmedical, according to data reported by the states.
Saad Omer, a professor of global health, epidemiology and pediatrics at Emory University, said that an analysis he and colleagues conducted a few years ago found the rate nonmedical exemptions had appeared to stabilize by the 2015-2016 school year after many years of increase.
But the latest CDC data appears to reflect a change, he said. “It seems that in recent years, exemptions are going up, and the trend is likely due to parents refusing to vaccinate,” he said.
In the 2017-2018 school year, 2.2 percent of U.S. kindergartners were exempted from one or more vaccines, up from 2 percent in the 2016-2017 school year and from 1.9 percent in the 2015-2016 school year, according to the CDC report.
Reasons for the increase couldn’t be determined from the data reported to CDC, the agency said. But researchers said factors could include the ease of obtaining exemptions or parents’ hesitancy or refusal to vaccinate.
States such as West Virginia and Mississippi, which do not allow nonmedical vaccine exemptions, have higher percentages of children getting vaccinated, said Mobeen Rathore, a pediatric infectious disease physician in Jacksonville, Fla., and a spokesman for the American Academy of Pediatrics (AAP).
Earlier this year, researchers from several Texas academic centers identified “hotspots” where outbreak risk is rising in 12 of 18 states that allow nonmedical exemptions because a growing number of kindergartners have not been vaccinated.
By Brian Fung
The Washington PostOctober 10
Antitrust officials gave CVS the green light on Wednesday to purchase Aetna, the nation’s third-largest health insurance company, in a $69 billion deal that could potentially transform the health-care industry and change how millions of Americans receive basic medical services.
The Justice Department approved the deal on the condition that the companies sell off Aetna’s Medicare Part D prescription drug business.
The tie-up will allow CVS — whose retail pharmacy business serves 5 million customers a day — to turn more of its brick-and-mortar locations into front-line clinics for basic medical services and patient monitoring. By deepening its knowledge of and relationships with patients, CVS has said the combination could help Americans stick with medication regimens and stay out of the hospital.
Driving that new approach to care will be the immense amounts of data generated not only by CVS’s 9,800 retail outlets and 1,100 MinuteClinics but also from Aetna’s 22 million medical members.
The result could make CVS a destination for more than flu shots and treatment of minor illnesses.
“Our focus will be at the local and community level,” CVS chief executive Larry Merlo said in a statement, “to intervene with consumers to help predict and prevent potential health problems before they occur.”
Much of the U.S. health-care system revolves around fixing costly ailments. But in trying to head off the worst cases, CVS and Aetna are aiming to become a part of the nation’s social fabric, using the local retail pharmacy as both a window into people’s lives beyond the doctor’s office and assuming the role of a health-care assistant.
The CVS merger could lead to a future in which the company coordinates transportation for patients who have difficulty showing up for routine medical appointments, Aetna chief executive Mark Bertolini has said. That help could extend to nutrition counseling or even the use of wearable devices that automatically notify patients and health-care providers of a potential problem.
The Aetna acquisition is also expected to give CVS more leverage in its negotiations with drugmakers over drug prices, analysts say. A substantial share of CVS’s revenue comes from its role as a “pharmacy benefit manager” for insurance companies and employers. As health-care costs have risen, PBMs have emerged as important power players in the pharmaceutical supply chain.
Critics of the CVS-Aetna deal had worried that the merger could lead to higher drug prices for Medicare Part D beneficiaries. Opponents such as the American Medical Association also said the acquisition could increase insurance premiums and out-of-pocket expenses more broadly.
“The AMA worked tirelessly to oppose this merger and presented a wealth of expert empirical evidence to convince regulators that the merger would harm patients,” the AMA’s president, Barbara McAneny, said Wednesday in a statement. “We now urge the DOJ and state antitrust enforcers to monitor the post-merger effects of the Aetna acquisition.”
The Justice Department said Wednesday that although the deal as originally proposed could have resulted in harms to competition, the two companies’ divestiture of Aetna’s Medicare pharmacy service effectively addresses the issue.
"Today’s settlement resolves competition concerns posed by this transaction and preserves competition in the sale of Medicare Part D prescription drug plans for individuals,” said Makan Delrahim, the Justice Department’s antitrust chief, in a statement.
The marriage of the two firms underscores a wider trend toward consolidation in the health-care sector, and analysts said the CVS deal is likely to spur more acquisitions in the industry. The Justice Department’s announcement follows a decision last month by regulators to bless a similar PBM deal involving the insurance company Cigna and Express Scripts.
"The Cigna-Scripts and CVS-Aetna deals are doing what everyone else in the health-care space is doing right now, just on a grander scale — reacting to continued cost pressures from market forces like the ACA, consumerism and other industry players building scale against each other,” said Brad Haller, a director specializing in mergers and acquisitions at the firm West Monroe.
The industry faces outside pressures, as well, from technology firms who increasingly view health care as a market opportunity.
Amazon.com, for example, is seeking to challenge the traditional dominance of drugstores by selling over-the-counter medicines and supplements. (Amazon chief executive Jeffrey P. Bezos owns The Washington Post.) And the company is partnering with Berkshire Hathaway and J.P. Morgan on a venture to reduce costs in the health-care industry by targeting middlemen.
Surveys show that the public is optimistic about the tech industry’s efforts to reshape health care. More than half of Americans said they were very or somewhat confident in the ability of Silicon Valley to reduce costs and make patient data more accessible, in a report published by the consulting firm PwC in April. But tech giants have come under growing scrutiny from regulators for their privacy practices.
On Wednesday, the top law enforcement officials of three states — Connecticut, New Jersey and Washington state — and the District of Columbia announced they had reached settlements with Aetna resolving allegations that the company had mishandled patient information and violated their privacy. Aetna had allegedly mailed notices regarding HIV medications to roughly 12,000 individuals across the country using envelopes with large windows, allowing the patients' HIV status to be revealed, according to the state officials. The company has agreed to pay fines to each state and to change its privacy and security policies.
The CVS deal is expected to close by the end of the year.
Patients in your exam room may be experiencing one of a number of forms of abuse—domestic violence, human trafficking or other violence—and identifying those being abused can sometimes be tough.
How physicians can identify, assist trafficking victims
An article published in the AMA Journal of Ethics® outlined the challenges and identified ways for physicians to better spot and help trafficking victims. The authors noted that a 2014 study found that 88 percent of victims had contact with a health professional while being trafficked, but none were identified or offered help in getting out of their situation during the medical encounter.
Family physician Anita Ravi, MD, MPH, MSHP, discovered that she has had to rethink the way she approaches patients to best help those facing abuse or violence. The founder and medical director of the PurpLE (Purpose: Listen & Engage) Clinic at the Institute for Family Health in New York City offers a health home for those who have been victims of human trafficking and other trauma.
Dr. Ravi said her experience, including a study that involved interviewing 30 sex-trafficking survivors about their interactions with the health care system, has taught her that patients experiencing violence or abuse can be of any gender, age, documentation status or background and they may be encountering a range of medical issues. It may be a patient who has never encountered the health care system before because traffickers deny their access to care or the person seeking care was never able to leave their abuser long enough to seek medical care.
Patients have told her there were times when they have left a medical setting because they felt they were being judged.
“We need to think differently about people we deem “frequent flyers”,” Dr. Ravi said. For example, a patient may be coming in for frequent sexually transmitted disease testing because they are being forced to have unprotected sex.
She said physicians need to be nonjudgmental and let people know that mental health, housing, legal and social services are available. While a patient may not open up to what is really going on during a first or even second visit, those interactions can lay the groundwork that the physician’s office or an emergency department is a safe place.
Dr. Ravi said it is also important to establish a policy—even putting it in writing in the exam and waiting rooms—that says a patient needs to be seen one-on-one for part of the visit. Often, trafficked patients will come in with a man or woman who is trafficking them; sometimes that person could even be a relative.
The AMA Code of Medical Ethics offers physicians guidance on their obligation to take appropriate action to help patients avert harms that violence and abuse cause.
What physicians can do individually
In Opinion 8.10, “Preventing, Identifying and Treating Violence and Abuse,” the Code explains that all patients may be at risk for interpersonal violence and abuse, which may adversely affect a patient’s health or ability to adhere to medical recommendations. Physicians, in light of their obligation to promote the well-being of patients, have an ethical obligation to take appropriate action to avert the harms caused by violence and abuse.
The Code says to protect patients’ well-being, physicians individually should become familiar with:
How to detect violence or abuse, including cultural variations in response to abuse.
Community and health resources available to abused or vulnerable persons.
Public health measures that are effective in preventing violence and abuse.
Legal requirements for reporting violence or abuse.
Physicians also should:
Consider abuse as a possible factor in the presentation of medical complaints.
Routinely inquire about physical, sexual, and psychological abuse as part of the medical history.
Not allow diagnosis or treatment to be influenced by misconceptions about abuse, including beliefs that abuse is rare, does not occur in “normal” families, is a private matter best resolved without outside interference, or is caused by victims’ own actions.
Treat the immediate symptoms and sequelae of violence and abuse and provide ongoing care for patients to address long-term consequences that may arise from being exposed to violence and abuse.
Discuss any suspicion of abuse sensitively with the patient, whether or not reporting is legally mandated, and direct the patient to appropriate community resources.
Report suspected violence and abuse in keeping with applicable requirements.
What to consider before reporting
Before reporting suspected violence or abuse, the Code says physicians should inform patients about requirements to report.
Obtain the patient’s informed consent when reporting is not required by law. Exceptions can be made if a physician reasonably believes that a patient’s refusal to authorize reporting is coerced and therefore does not constitute a valid informed treatment decision.
Physicians should also protect patient privacy when reporting by disclosing only the minimum necessary information.
Tanya Albert Henry
“INFLUENZA 2018-19” WEBINAR OCTOBER 17TH REGISTRATION NOW OPEN
“Medical Matters” will begin its 2019 webinar series with “Influenza 2018-19” on Wednesday, October 17, 2018 at 7:30 a.m. Registration is now open for this webinar here.
William Valenti, MD, chair of MSSNY Infectious Disease Committee and a member of the Emergency Preparedness and Disaster/Terrorism Response Committee will serve as faculty for this program.
The educational objectives are: 1) Describe key indicators to look for when diagnosing patients presenting with flu-like symptoms. 2) Describe clinical and laboratory diagnostic features and treatment specific to each flu season. 3) Identify recommended immunizations and antiviral medications for treatment and how best to effectively encourage patients to get vaccinated.
Medical Matters is a series of Continuing Medical Education (CME) webinars sponsored by MSSNY’s Committee on Emergency Preparedness and Disaster/Terrorism Response. A copy of the flyer can be accessed here.
The Medical Society of the State of New York is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
The Medical Society of the State of New York designates this live activity for a maximum of 1.0 AMA/PRA Category 1 credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Additional Medical Matters programs will be conducted on November 14, 2018 – June, 2019. Registration is also open for the November 14, 2018 program: Cybersecurity: A Daily Threat for Healthcare here. Additional program dates for Medical Matters will be announced shortly.
Additional information or assistance with registration may be obtained by contacting Melissa Hoffman at firstname.lastname@example.org.
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